title: Are all skilled birth attendants created equal? A cluster randomised controlled study of non-physician based obstetric care in primary health care clinics in Mexico.
abstract: BACKGROUND
  the great majority of births in Mexico are attended by physicians. Non-physician health professionals have never been evaluated or compared to the medical model of obstetric care. This study evaluates the relative strengths of adding an obstetric nurse or professional midwife to the physician based team in rural clinics.
  
  
  METHODS
  we undertook a cluster-randomised trial in 27 clinics in 2 states with high maternal mortality. Twelve non-physician providers (obstetric nurses (4) and professional midwives (8)) were randomly assigned to clinics; 15 clinics served as control sites. Over an 18-month period in 2009-2010, we evaluated quality of care through chart review and monthly interviews with providers about last three deliveries performed. We analysed practices by creating indices using WHO care guidelines for normal labour and childbirth. Volume of care was assessed using administrative reporting forms.
  
  
  RESULTS
  two thousand two hundred fifty-four pregnancies were followed, and a total of 461 deliveries occurred in study sites. Intervention clinics were more likely to score highly on the index for favourable practices on admission (OR=3.6, 95% CI 2.3-5.8), and during labour, childbirth, and immediately post partum (OR=8.6, 95% CI 2.9-25.6) and less likely to use excessively used or harmful practices during labour, childbirth and immediately post partum (OR=0.2, 95% CI 0.1-0.4). There was a significant increase in volume of care in intervention clinics for antenatal visits (incidence rate ratio (IRR) 1.3, 95% CI 1.2-1.4), deliveries (IRR=2.5, 95% CI 1.7-3.7) and for postpartum visits (IRR=1.4, 95% CI 1.1-1.7).
  
  
  CONCLUSIONS
  the addition of non-physician skilled birth attendants to rural clinics in Mexico where they independently provided basic obstetric services led to improved care and higher coverage than clinics without. The potential value of including a professional midwife or obstetric nurse in all rural clinics providing obstetric care should be considered.
  
  
  BACKGROUND
  Mexican National Institute for Women, Mexican National Center for Gender Equity and Reproductive Health, MacArthur Foundation, Bill and Melinda Gates Foundation.
authors.affiliation: Department of Obstetrics and Gynecology and Global Health, University of Washington, 325 9th Ave, Box 359931, Seattle, WA 98104, USA; Mexican National Institute of Public Health, Center for Population Research, Department of Reproductive Health, Av. Universidad 655, Cerrada los Pinos y Caminera, Col. Sta. Ma. Ahuacatitlan, Cuernavaca, Morelos C.P. 62100, Mexico. Electronic address: dilys@u.washington.edu.
authors.forename: Dilys
authors.initials: D
authors.lastname: Walker
authors.forename: Lisa
authors.initials: L
authors.lastname: DeMaria
authors.forename: Dolores
authors.initials: D
authors.lastname: Gonzalez-Hernandez
authors.forename: Aldanely
authors.initials: A
authors.lastname: Padron-Salas
authors.forename: Minerva
authors.initials: M
authors.lastname: Romero-Alvarez
authors.forename: Leticia
authors.initials: L
authors.lastname: Suarez
mesh_terms: D000328:Adult; D002983:Clinical Competence; D015400:Clinical Nursing Research; D036861:Delivery, Obstetric / Q000379:methods / Q000401:mortality / Q000592:standards; D005260:Female; D006801:Humans; D008428:Maternal Mortality; D008800:Mexico; D008880:Midwifery / Q000379:methods / Q000592:standards; D009773:Obstetric Nursing / Q000379:methods / Q000592:standards; D018743:Perinatal Care / Q000379:methods / Q000458:organization & administration; D011247:Pregnancy; D011256:Pregnancy Outcome; D011320:Primary Health Care / Q000379:methods / Q000458:organization & administration; D058996:Quality Improvement; D019035:Rural Health Services / Q000592:standards
keywords: Evidence based medicine; Mexico; Quality of care; Skilled birth attendant